Provider Demographics
NPI:1265429724
Name:MILLER, ELZIE IRVIN III (DDS)
Entity type:Individual
Prefix:DR
First Name:ELZIE
Middle Name:IRVIN
Last Name:MILLER
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 S ENTERPRISE AVE
Mailing Address - Street 2:A-3
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1850
Mailing Address - Country:US
Mailing Address - Phone:417-881-1213
Mailing Address - Fax:
Practice Address - Street 1:1655 S ENTERPRISE AVE
Practice Address - Street 2:A-3
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1850
Practice Address - Country:US
Practice Address - Phone:417-881-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice